<%@ page language="java" contentType="text/html; charset=ISO-8859-1"
    pageEncoding="ISO-8859-1"%>
<%@ taglib prefix="form" uri="http://www.springframework.org/tags/form"%>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib prefix="sec" uri="http://www.springframework.org/security/tags" %> 
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<link rel="stylesheet" href="resources/mytheme/css/main.css">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<title>View Claim</title>
</head>
<body>
	<div id="headerContainer">
		<div class="centerContainer">
			<ol>
			<sec:authorize ifAllGranted="ROLE_ADMIN">
				<li><a href="AdminUsers">Users</a></li>
				<li><a href="AdminRejectedClaims">Rejected Claims</a></li>
				<li><a href="AdminAcceptedClaims">Accepted Claims</a></li>
				<li><a href="AdminAllClaims">All Claims</a></li>
			</sec:authorize>
			<sec:authorize ifAnyGranted="ROLE_ADMIN, ROLE_ADJUSTER">
				<li><a href="InsuranceAdjuster">Adjust Claims</a></li>
			</sec:authorize>
			</ol>
		</div>
		<!-- /centerContainer -->

	</div>
	<!-- /headerContainer -->

	<div id="secondHeaderContainer">
		<div class="logoContainer">
			<img src="resources/mytheme/images/logo2.png" alt="logo" width="205"
				height="89">
		</div>
		<!-- /logoContainer -->
		<div class="navContainer">

			<ul id="navWrapper">
				<li><a href="/AcmeClaims">Home</a></li>
				<sec:authorize ifNotGranted="ROLE_ADMIN">
				<c:if test="${pageContext.request.userPrincipal.name != null}">
					<li>
						<!-- Menu A --> <a href="#">Claims</a>
						<ul>
							<li><a href="ClaimPortal">Submit Claim</a></li>
							<li><a href="MyAccount">View Claim</a></li>
						</ul>
					</li>
					<li><a href="MyAccount">My Account</a></li>
				</c:if>
				</sec:authorize>
				<li><a href="locatedoctor">Find a Doctor</a></li>
			</ul>
		</div>
		<!-- /navContainer -->
	</div>
	<!-- /secondHeaderContainer -->
	<div id="homemainCenterHolder2">
	<div id="homemainCenterHolder">
		<div id="mainCenterHolder">
		
			<div class="mainCenterContainerClaimReview">
				<form:form commandName="claim" action="downloadPDF" target="login.do">
					<table>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Claim Review</h2>
							</td>
						</tr>
						<tr class="d0">
							<td width="100px">First Name: </td>
							<td>${claim.user.fName}</td>
						</tr>
						<tr class="d1">
							<td width="100px">Last Name: </td>
							<td>${claim.user.lName}</td>
						</tr>
						<tr class="d0">
							<td width="80px"> Gender  </td>
							<td>${claim.user.gender}</td>
						</tr>
						<tr class="d1">
							<td> Identification Number </td>
							<td>${claim.user.insuranceNumber}</td>
						</tr>
						<tr class="d0">
							<td> Date of Birth </td>
							<td>${claim.user.birthday}</td>
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Injury Information</h2>
							</td>
						</tr>
						<tr class="d1">
							<td width="200px">A) Accident or Illness due to employment? </td>
							<td width="500px">${claim.jobRelated}</td>
						</tr>
						<tr class="d0">
							<td width="200px">B) Is this service related to: </td>
							<td>${claim.type}</td>
						</tr>
						<tr class="d1">
							<td width="200px">D) Date of Accident or Beginning of Illness  </td>
							<td>${claim.date}</td> 
						</tr> 
						<tr class="d0">
							<td width="200px">C) Symptom/Diagnosis </td>
							<td>${claim.diagnosis}</td>
						</tr>
						<tr class="d1">
							<td width="200px">E) Were you hospitalize</td>
							<td>${claim.hospitalized}</td>
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Hospital Information</h2> 
							</td>
						</tr>
						<tr class="d0">
							<td>Hospital Name </td>
							<td>${claim.hospitalName}</td>
						</tr>
						<tr class="d1">
							<td>Admission Date </td>
							<td>${claim.hospAdmitDate}</td>
						</tr>
						<tr class="d0">
							<td>Discharge Date </td>
							<td>${claim.hospDischargeDate}</td>
						</tr>
						<tr class="d1">
							<td>Name of Physician</td>
							<td>${claim.admittingPhysician}</td> 
						</tr>
						<tr>
							<td colspan="2" style="text-align: left">
								<h2>Insurance Information</h2>
							</td>
						</tr>
						<tr class="d0">
							<td>Do you have Medicare coverage? </td>
							<td>${claim.medicare}</td>
						</tr>
						<tr class="d1">
							<td>Medicare Number </td>
							<td>${claim.medicareNumber}</td>
						</tr>
						<tr class="d0">
							<td>Eligible for Medicare Part A? </td>
							<td>${claim.medicareA}</td>
						</tr>
						<tr class="d1">
							<td>Eligible for Medicare Part B? </td>
							<td>${claim.medicareB}</td>
						</tr>
						<tr class="d0">
							<td>Do you have other insurance coverage? </td>
							<td>${claim.otherInsurance}</td>
						</tr>
						<tr class="d1">
							<td>Name of Insurance Company </td>
							<td>${claim.otherInsCompName}</td>
						</tr>
						<tr class="d0">
							<td>Identification Number </td>
							<td>${claim.otherInsCompID}</td>
						</tr>
					</table>
					<br>
					<center>
						<div>
							<input type="submit" value="View PDF File" name="_viewPDF">
						</div>
					</center>
				</form:form>
			</div>
			</div>
		</div>
	</div>
	<div id="footer">
		<div class="footerwrap">
			<div class="foota">
				<br>
				<p>Connect With Us</p>
				<div id="footapad">
					<a href="#"><img src="resources/mytheme/images/fb.png" id="facebook" alt="logo" width="67" height="73"/></a>
					<a href="#"><img src="resources/mytheme/images/twit.png" id="twitter" alt="logo" width="65" height="73"/></a>
					<a href="#"><img src="resources/mytheme/images/pin.png" id="pintrest" alt="logo" width="67" height="73"/></a>
				</div>
			</div>
			<div class="footb">
			<br>
				<p>Toll Free: 1-800-382-3827</p>
				  <ol>
					<li>Acme Corporate</li>
					<li>143 23rd Ave South</li>
					<li>Fargo, North Dakota 58121</li>
				</ol>
			</div>
			<div class="footc">
			<br>
				<p>Need Help?</p>
				  <ol>
					<li><a href="#">Contact Us</a></li>
					<li><a href="#">Get Directions</a></li>
					<li><a href="#">FAQ's</a></li>
				</ol>
				 
			</div>
		</div><!-- FooterWrap -->
	</div><!-- Footer -->
</body>
</html>